The impact of prenatal care on postneonatal deaths in the presence and absence of antenatal high-risk conditions

OBJECTIVE: This study was undertaken to determine the association, if any, between prenatal care and postneonatal death in the presence and absence of high-risk pregnancy conditions. STUDY DESIGN: Data were derived from the national linked birth/infant death data set for the years 1995 to 1997 provided by the National Center for Health Statistics. Analyses were restricted to singleton live births that occurred after 23 completed weeks of gestation. Multiple births, congenital malformations, chromosomal abnormalities, missing data on gestational age, and birth weight less than 500 g were excluded. Multivariable logistic regression analyses were used to adjust for various antenatal high-risk conditions, maternal age, gravidity, gestational age at delivery, birth weight, maternal education, marital status, smoking, and alcohol use. Postneonatal death rate was defined as the number of deaths between 28 and 365 days of life per 1,000 neonatal survivors. RESULTS: For 10,512,269 singleton live births analyzed, 21,962 (2.1 per 1,000) resulted in postneonatal death. Postneonatal death rates were higher for African American women than white women in the presence (3.8 vs 1.7 per 1,000) and absence (11.2 vs 5.3 per 1,000) of prenatal care. Lack of prenatal care was associated with increased relative risk (RR) for postneonatal death, 1.8-fold in African American women and 1.6-fold in white women. Lack of prenatal care was associated with increased postneonatal death rates to a similar degree for the individual high-risk pregnancy conditions for both African American and white women. Lack of prenatal care was associated with increased postneonatal death rates, especially in the presence of postterm pregnancy (RR 2.3, 95% CI 1.6, 3.1), pregnancy-induced hypertension (RR 2.2, 95% CI 1.5, 3.4), intrapartum fever (RR 2.1, 95% CI 1.2, 3.5), and small-for-gestational-age infant (RR 1.6, 95% CI 1.3, 2.0). CONCLUSION: Lack of prenatal care should be considered as a high-risk factor for postneonatal death for both African American and white women, especially if the pregnancy has been complicated by postdates, pregnancy-induced hypertension, intrapartum fever or small-for-gestational-age infant.     

The impact of prenatal care in the United States on preterm births in the presence and absence of antenatal high-risk conditions

OBJECTIVE: This study was undertaken to determine the association between prenatal care in the United States and preterm birth rate in the presence, as well as absence, of high-risk pregnancy conditions for African American and white women. STUDY DESIGN: Data were derived from the natality data set for the years 1995 to 1998 provided by the National Center for Health Statistics. Analyses were restricted to singleton live births that occurred at >/=20 weeks' gestation. Multiple births, fetal deaths, congenital malformations, chromosomal abnormalities, missing data on gestational age, and birth weight less than 500 g were excluded. Multivariable logistic regression analyses were used to adjust for the presence or absence of various antenatal high-risk conditions, maternal age, gravidity, marital status, smoking, alcohol, and education. Prenatal care was considered present if there was one or more prenatal visits. Preterm delivery was defined as delivery at less than 37 completed weeks of gestation. RESULTS: For 14,071,757 births analyzed, 1,348,643 (9.6%) resulted in preterm birth. Preterm birth rates were higher for African American women than white women in the presence (15.1% vs 8.3%) and absence (34.9% vs 21.9%) of prenatal care. The absence of prenatal care increased the relative risk for preterm birth 2.8-fold in both African American and white women. There was an inverse dose-response relationship between the number of prenatal visits and the gestational age at delivery both among African American and white women. Lack of prenatal care was associated with increased preterm birth rates to a similar degree in the presence of pregnancy complications for both African American and white women, ranging from 1.6-fold to 5.5-fold for the various antenatal high-risk conditions. CONCLUSION: In the United States, prenatal care is associated with fewer preterm births in the presence, as well as absence of high-risk conditions for both African American and white women. Strategies to increase prenatal care participation may decrease preterm birth rates.     

Adequacy of prenatal care and neonatal mortality in infants born to mothers with and without antenatal high-risk conditions

BACKGROUND: Previous studies have found that inadequate prenatal care was associated with increased neonatal mortality in the general pregnant women. AIMS: To examine the association between adequacy of prenatal care and neonatal mortality in the presence and absence of antenatal high-risk conditions. METHODS: We conducted a retrospective cohort study of infants based on 1995-2000 vital statistics data in the USA. The relative risk for neonatal death associated with adequacy of prenatal care was estimated by multivariate logistic regressions with adjustment of confounding factors. RESULTS: Inadequate prenatal care was associated with increased neonatal mortality when pregnancies were complicated by anaemia, cardiac disease, lung disease, chronic hypertension, diabetes, renal disease, pregnancy-induced hypertension, and previous preterm/small-for-gestational-age birth. The observed association also existed in the absence of these antenatal high-risk conditions. Overutilisation of prenatal care was associated with increased risk of neonatal deaths in both the presence and the absence of antenatal high-risk conditions. When gestational age at delivery and birthweight were further adjusted, the observed association between inadequate prenatal care and neonatal mortality was not significant in pregnancies with various high-risk conditions. CONCLUSIONS: Inadequate prenatal care is associated with increased neonatal death in both the presence and the absence of antenatal high-risk conditions. The observed association between inadequate prenatal care and neonatal mortality may be mediated by increased risk of preterm delivery and low birthweight in these pregnancies. Overutilisation of prenatal care is associated with potential risks for fetal and neonatal development, leading to increased neonatal mortality.     

Perinatal deaths and insufficient antenatal care in Latvia

OBJECTIVE: A national audit on perinatal deaths was performed to assess the quality of antenatal care, and to suggest measures for improved antenatal care. MATERIAL AND METHODS: Medical records of all the perinatal deaths in Latvia in the years 1995-1996 have been studied. Non-attenders and attenders of antenatal care were characterized by socio-economic and medical variables: maternal age, parity, history of perinatal outcome, health status and behavioral hazards during the index pregnancy, length of gestation and birth weight. The Nordic-Baltic perinatal death classification was used. RESULTS: In 85 of 442 cases (19%) of perinatal deaths women had not taken advantage of antenatal care provided for them. Non-attenders were more likely to be smokers (p<0.001) and alcohol abusers (p<0.005), above 35 years of age (p<0.005), and had higher parity (p<0.001). Non-attenders more often had systemic diseases and pregnancy complications. Neonatal complications, such as congenital syphilis (p<0.05) and other infections (p<0.05), were more common among non-attenders. There was no difference in rates of preterm birth and low birth weight between attenders and non-attenders. CONCLUSIONS: One fifth of mothers with perinatal death did not attend ANC, and in some women who attended ANC, lack of intervention was related to the perinatal death.     

The impact of antenatal cocaine use on maternal characteristics and neonatal outcomes

Objective: To determine the risk factors and evaluate maternal and neonatal outcomes associated with antenatal cocaine use.

Methods: This was a retrospective case–control study of 200 cocaine-exposed maternal–neonatal pairs and 200 controls from 1991 to 2000.

Results: Cocaine-using mothers tended to be older, African American, multiparous and incarcerated and they utilized less prenatal care. However, 79% of Hispanics abusing cocaine were primarily English speaking. Cocaine use correlated with syphilis (36 vs. 1%, p?=?0.000) and premature rupture of membranes (23 vs. 0%, p?=?0.000), fetal demise (5 vs. 0%, p?=?0.004), preterm delivery (40 vs. 6%, p?=?0.000). Cocaine-exposed infants delivered earlier (36 vs. 39 weeks, p?=?0.000), had lower birth weights (2660 vs. 3305?g, p?=?0.000), more respiratory distress syndrome (14 vs. 4%, p?=?0.001), congenital syphilis (12 vs. 1%, p?=?0.000) and longer hospital stays (10 vs. 3 days, p?=?0.000); 75% were placed in foster care or adoption and 37.5% had neonatal withdrawal syndrome. There was a stronger positive correlation between neonatal withdrawal and maternal urine toxicology (ρ?=?0.443, p?=?0.000) than with neonatal urine screen (ρ?=?0.278, p?=?0.003).

Conclusion: Cocaine use in pregnancy is associated with acculturation, lack of prenatal care, and significant social and obstetric complications resulting in increased neonatal morbidity secondary to prematurity, congenital infection and withdrawal syndrome.     

The impact of antenatal cocaine use on maternal characteristics and neonatal outcomes.

OBJECTIVE: To determine the risk factors and evaluate maternal and neonatal outcomes associated with antenatal cocaine use. METHODS: This was a retrospective case-control study of 200 cocaine-exposed maternal-neonatal pairs and 200 controls from 1991 to 2000. RESULTS: Cocaine-using mothers tended to be older, African American, multiparous and incarcerated and they utilized less prenatal care. However, 79% of Hispanics abusing cocaine were primarily English speaking. Cocaine use correlated with syphilis (36 vs. 1%, p = 0.000) and premature rupture of membranes (23 vs. 0%, p = 0.000), fetal demise (5 vs. 0%, p = 0.004), preterm delivery (40 vs. 6%, p = 0.000). Cocaine-exposed infants delivered earlier (36 vs. 39 weeks, p = 0.000), had lower birth weights (2660 vs. 3305 g, p = 0.000), more respiratory distress syndrome (14 vs. 4%, p = 0.001), congenital syphilis (12 vs. 1%, p = 0.000) and longer hospital stays (10 vs. 3 days, p = 0.000); 75% were placed in foster care or adoption and 37.5% had neonatal withdrawal syndrome. There was a stronger positive correlation between neonatal withdrawal and maternal urine toxicology (rho = 0.443, p = 0.000) than with neonatal urine screen (rho = 0.278, p = 0.003). CONCLUSION: Cocaine use in pregnancy is associated with acculturation, lack of prenatal care, and significant social and obstetric complications resulting in increased neonatal morbidity secondary to prematurity, congenital infection and withdrawal syndrome.     

The impact of prenatal care in different social groups

An analysis of United States birth certificate records for the calendar year 1977 indicated that women who failed to seek prenatal care were at increased risk of delivery of a low-birth weight infant, even after social factors were considered. However, the strength of association, as well as the population impact, between antenatal care and birth weight varied by social group. Prenatal care had the greatest observed impact for socially disadvantaged women, because of their high overall risk of delivery of low-birth weight infants. From these observations, it appears that the efficacy of antenatal services is modified by social situation. As a result, summary evaluations of prenatal care impact may underestimate the true value of these services for certain social groups.     

Esophageal atresia and tracheoesophageal fistula: the impact of prenatal suspicion on neonatal outcome in a tertiary care center

AIMS: To determine the impact of antenatal suspicion of esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) on neonatal outcome. METHODS: Retrospective review of all neonates with EA who received prenatal care including fetal ultrasound and delivery at our institution from 1990-2001. Cases with suspected EA on prenatal ultrasound (hydramnios and/or an absent stomach bubble) were identified. Neonatal outcome variables for the group suspected antenatally and the group diagnosed postnatally were compared. Mann Whitney U and Fischer exact tests were used in analysis. RESULTS: Twenty-two patients met inclusion criteria. Nine cases (40.9%) had prenatal ultrasound findings associated with EA/TEF. There was no statistically significant difference in the incidence of preterm delivery, intrauterine growth restriction, respiratory distress syndrome, additional anomalies or neonatal death, birth weight, requirement for preoperative and postoperative mechanical ventilation or length of hospital stay between the prenatally suspected and postnatally diagnosed groups. There were two neonatal demises: one had trisomy 18 and one was born prematurely at 29 weeks. CONCLUSIONS: In our experience, prenatal detection of ultrasound findings associated with EA/TEF does not affect neonatal outcome or identify a group at increased risk for neonatal morbidity and mortality. Our favorable outcomes, with or without prenatal suspicion, may reflect the comprehensive care readily available at a tertiary care facility. Larger series need to be studied to exclude the possibility of a type II error.     

The impact of a dedicated antenatal clinic on the obstetric and neonatal outcomes in adolescent pregnant women.

This retrospective observational study was designed to study the impact of a dedicated antenatal clinic service on obstetric and neonatal outcomes among teenage mothers in the maternity unit of a district general hospital in the UK. Outcomes were measured to investigate improvement in obstetric and neonatal outcomes before, and 12 months after the establishment of dedicated clinic for teenage pregnant women. Significant improvement in the birth weight was observed p = 0.01. A modest decrease in neonatal admission to special care unit by 6% was observed. Rate of spontaneous vaginal deliveries increased p = 0.0009. There was significant uptake of contraception and continuation of breast-feeding in this group of young women (p < 0.0001).     

The quality of antenatal care in Turkey and the role of ultrasonography in the antenatal care system

OBJECTIVE: The aim of this study was to determine the quality of antenatal care and the role of routine obstetric ultrasonography (US) in Turkey's antenatal care program. MATERIALS AND METHOD: Two surveys consisting of 11 questions were conducted on 295 patients without pregnancy associated risk in 1995 and on 208 patients in 2000, during the first 24 h after delivery. The results of the two surveys were compared. A P value of <0.05 was used to denote statistical significance. RESULTS: When the results of the two surveys were compared, we found that in 2000, patients had started their antenatal visits earlier in pregnancy than those in 1995 and basic laboratory tests, such as complete blood count, urinalysis, and diabetes screening had been performed on an increased number of patients receiving antenatal care outside our clinic. Ultrasonographic examination was performed on all of the patients during their antenatal visits in 2000, while only 76.6% of the cases were examined by US in 1995. The number of ultrasound examinations per antenatal visit had significantly increased (0.47 in 1995 versus 0.6 in 2000, [Odds ratio: 1.277, 95% confidence interval: 1.12-1.44]). Data from 2000 has shown that 8.7% (5/57) of the patients who received antenatal care outside our clinic (Group 1) had been examined using US at least 10 times. However, 17.5% of these patients had not undergone a complete blood count (CBC) or urinalysis and blood pressure had not been measured at all in 5.2% of cases. CONCLUSION: Despite some differences, we believe that the situation in Turkey is similar to that in the rest of the world. The expectations women have of ultrasound examination are much higher than can be realised in reality. In Turkey, it appears that many physicians, especially those based in large cities, rely on highly technical procedures like ultrasonography and neglect the basics of antenatal care (blood pressure measurements, complete blood counts, urinalysis, diabetes screening etc.).     

Fetal deaths in the United States. Influence of high-risk conditions and implications for management

OBJECTIVE: To estimate the effect of specific maternal-fetal high-risk conditions on the risk and timing of fetal death. METHODS: This study examined 10,614,679 non-anomalous singleton pregnancies delivering at or beyond 24 weeks' gestation, derived from the U.S. linked birth/infant death data sets, 1995-1997. Fetal death rates for pregnancies at low risk were compared with pregnancies complicated by chronic hypertension, gestational hypertensive disorders, diabetes, small for gestational age infants, and abruption. Adjusted relative risks as well as population-attributable risks for fetal death were derived by gestational age for each high-risk condition compared with low-risk pregnancies. RESULTS: The fetal death rate for low-risk pregnancies was 1.6 per 1000 births. Adjusted relative risk for fetal death was 9.2 (95% confidence interval [CI] 8.8, 9.7) for abruption, 7.0 (95% CI 6.8, 7.2) for small for gestational age infants, 1.4 (95% CI 1.3, 1.5) for gestational hypertensive disorders, 2.7 (95% CI 2.4, 3.0) for chronic hypertension, and 2.5 (95% CI 2.3, 2.7) for diabetes. Fetal death rates were lowest between 38 and 41 weeks. The fetal death rate (per 1000 births) for these high-risk conditions was 61.4, 9.6, 3.5, 7.6, and 3.9, respectively. Almost two thirds of fetal deaths were attributable to the pregnancy complications examined. CONCLUSION: High-risk conditions in pregnancy are associated with an increased risk for fetal death, particularly in the third trimester. Delivery should be considered at 38 weeks, but no later than 41 weeks, for these pregnancies.     

The perinatal and economic impact of prenatal care in a low-socioeconomic population

Reductions in publicly funded prenatal care programs in 1981 to 1984 resulted in an increase in unregistered patient deliveries from 7.8% to 14.9% of births at University of California San Diego Medical Center. To assess the economic and perinatal impact of the increasing number of deliveries of women without prenatal care, 100 consecutive patients with fewer than three prenatal visits were studied. Each "no care" patient was matched by age, parity, and week of delivery with a control patient who received care in a state-funded perinatal project (Comprehensive Perinatal Program). Maternal antenatal risk factors were equally distributed between the two groups when maternal age, parity, history of substance abuse, prior preterm delivery, hypertension, and abortion were compared. Maternal obstetric outcomes were similar, including cesarean section rate and incidence of postpartum fever and hemorrhage. However, neonates delivered of women receiving no care experienced significantly greater morbidity than the neonates of women in the Comprehensive Perinatal Program, including an increased incidence of premature rupture of the membranes and preterm delivery (13% versus 2%, p less than 0.05), low birth weight (21% versus 6% less than 2500 gm, p less than 0.002), and intensive care unit admissions (24% versus 10%, p less than 0.005). When the total inpatient hospital charges were tabulated for each mother-baby pair, the cost of perinatal care for the group receiving no care ($5168 per pair) was significantly higher than the cost for patients in the Comprehensive Perinatal Program ($2974 per pair, p less than 0.001) including an antenatal charge of $600 in the Comprehensive Perinatal Program. The excess cost for delivery of 400 women receiving no care per year in the study hospital was $877,600. These results suggest that extension of prenatal care programs to medically indigent women is likely to result in a net reduction in perinatal morbidity and health care expenditures.     

The radiology of stillbirths and neonatal deaths

Summary. Whole body radiographs were made in a consecutive series of 488 infants who were either stillborn or died within the first month of life; autopsies were done in 378. The radiographs were considered to have been useful, or diagnostic in 16% overall, in 100% of infants with dwarfism, in 40% where there were external malformations; and in 9% where there were no external malformations.     

The radiology of stillbirths and neonatal deaths

Whole body radiographs were made in a consecutive series of 488 infants who were either stillborn or died within the first month of life; autopsies were done in 378. The radiographs were considered to have been useful, or diagnostic in 16% overall, in 100% of infants with dwarfism, in 40% where there were external malformations; and in 9% where there were no external malformations.     

Does prenatal care decrease the incidence and cost of neonatal intensive care admissions?

This study was conducted to examine the potential effects of expanded Medicaid coverage for low income women. Statewide birth data for 1983 to 1985 were examined to determine the relationship between prenatal care and admissions to neonatal intensive care units (NICUs) and the costs of this care. An NICU sample was constituted from infants who were discharged live following more than 7 NICU days, were referred to an out of state tertiary center, or died following NICU admission. Inadequate care (no prenatal care, only last trimester care, or less than five visits) was received by 11% of the total birth cohort and by 18% of the infants in the NICU sample (p less than 0.001). Infants with inadequate care had a NICU admission rate of 5.10% versus 2.86% for those with adequate prenatal care (p less than 0.001). The hospital billings for infants in the NICU sample with inadequate care were significantly higher than were those for infants with adequate care (p less than 0.05). Assuming that economic resources limit access to prenatal care, the projection can be made that had all women with inadequate prenatal care received Medicaid-covered adequate prenatal care, expenditure for this care would yield more than a two to one return in savings in NICU costs.     

The impact of prenatal care on fetal and neonatal death rates for uninsured patients: a "natural experiment" in West Virginia.

A three-county program in southern West Virginia was developed by an obstetric practice to deliver prenatal care to a population of uninsured patients. Between January 1984 and December 1986, 1331 (29.4%) of 4534 patients were delivered at a level 2 hospital after prenatal care within the clinic program. The hospital-wide fetal death ratio declined from 11.8 to 7.2 per 1000 live births during the years of clinic operation, a statistically significant reduction (P = .02). Uninsured patients experienced a statistically significant reduction in fetal death ratio during the program, from 35.4 to 7.0 per 1000 live births (P = .02), whereas those covered by medical assistance did not experience a reduction. Privately insured patients also had a significant decrease, from 10.0 to 3.1 per 1000 live births (P less than .001). The increasing operating expense, mainly due to rising malpractice insurance premiums, required suspension of the program in December 1986. The fetal death ratio returned to 10.3 deaths per 1000 live births in 1987. Factors that varied significantly during the "clinic" phase included: higher rates of cesarean, diagnosed maternal hypertension, and diabetes mellitus; and lower rates of premature rupture of membranes and non-white population. Other factors, including age over 35 years, postdatism, incidence of twins, incidence of lethal congenital anomalies, and single marital status, did not vary significantly before, during, or after the clinic program. This study identified a high-risk population of patients who did not qualify for medical assistance coverage and were de facto "uninsured." The results suggest that prenatal care for this high-risk population of uninsured patients can reduce the fetal death rate.     

Information on prenatal diagnosis at the antenatal clinic. The women's experiences

The issue of information and autonomy (informed consent) in prenatal diagnosis (PND) was studied by questionnaires given to women undergoing amniocentesis (group A, n = 122) or chorionic villus biopsy (group V, n = 90). About 1/4 of the women were also interviewed. Sixty-eight percent of the women had learnt most about PND already before visiting the antenatal clinic. More women in group A (75%) than in group V (51%) were satisfied with the information given at the clinic, probably because amniocentesis is a well-known routine, while chorionic villus biopsy is not. Further, in both groups, more of the women who underwent PND because of age were satisfied with the information than those having PND because of strong fear of giving birth to a handicapped baby. This might be explained by the complicated character of this fear, which the medical staff could not always understand and meet. Also the women who were investigated because of a known genetic problem seemed to need more specialized genetic counselling. Fifty-eight percent of the women were well informed about the risk of giving birth to a child with a congenital disorder and 83% about which disorders could be detected by the procedure they were undergoing. Seventy-three percent had not felt any uneasiness when they were offered PND by their midwife or gynecologist; 18% had initiated the discussion themselves. Seventy-four percent of the women recommended that the medical staff actively offered PND. Most women (87%) answered that the midwife's or gynecologist's attitude towards PND had been positive. The majority (85%) considered that there is a risk of persuasion in counselling.(ABSTRACT TRUNCATED AT 250 WORDS)